Periodontal therapy using local delivery of antimicrobial agents

The economic and societal impact of periodontal and peri-implant diseases

Periodontal and peri-implant diseases result from a chronic inflammatory response to dysbiotic microbial communities and are characterized by inflammation in the soft tissue and the ensuing progressive destruction of supporting bone, resulting in tooth or implant loss. These diseases' high prevalence, multifactorial etiology, extensive treatment costs, and significant detriment to patients' quality-of-life underscore their status as a critical public health burden. This review delineates the economic and sociocultural ramifications of periodontal and peri-implant diseases on patient welfare and healthcare economics. We delve into the implications of diagnosis, treatment, supportive care, and managing destructive tissue consequences, contrasting these aspects with healthy patients.

Economic evaluations in the treatment and evaluation of patients with periodontal disease: A critical review

AIM

To evaluate the types and quality of reporting of economic evaluations carried out in the clinical management of periodontal disease over 32 years from 1987 to 2019.

MATERIAL AND METHODS

A systematic search of articles from 1987 to 2019 was conducted using PubMed, Web of Science, The Cochrane Central Register of Controlled Trials, Health Technology Assessment Database and Embase. The quality of the economic evaluations was assessed based on the Consolidated Health Economic Evaluation Reporting Standard checklist. Due to considerable between-study heterogeneity, a meta-analysis was not performed.

RESULTS

Twenty one publications were included. 11 studies used cost-effectiveness analysis, five used cost-minimization analysis, four used cost-utility analysis and two used cost-benefit analysis. Comparators, choice of health outcomes, estimating resources and costs were fully reported in all studies. Many studies had inadequate reporting in terms of estimating resources and costs, choice of health outcomes, characterizing heterogeneity and study perspective.

CONCLUSIONS

There has been an increase in health economics studies in the field of clinical periodontology over the past decade. Several studies did not report study perspective, and the health outcomes chosen were not relevant for some studies. Future studies should follow an economic evaluation checklist for high-quality reporting and consistency.

Commercial Local Pharmacotherapeutics and Adjunctive Agents for Nonsurgical Treatment of Periodontitis: A Contemporary Review of Clinical Efficacies and Challenges

Periodontal infections tend to be site-specific, mostly confined to the periodontal pocket. With the surge of antibiotic-resistant bacteria, the trend is shifting towards other therapeutic modalities, especially locally delivered approaches that include other pharmacotherapeutic drugs and medical devices. This narrative review aimed to provide insights into the clinical efficacy of local drug delivery and adjunctive agents used in nonsurgical management of periodontitis. Electronic (PubMed/MEDLINE, CENTRAL, and EMBASE) and bibliographic searches of past systematic reviews were carried out to identify previous publications on the topic. Only relevant literature and randomized controlled trials published in English were selected. In addition, a literature review was developed based on the selected articles. Experimental drugs or agents were excluded. This review highlights the clinically proven and commercially available therapeutic agents related to the management of periodontal disease with comparisons of their clinical efficacies and challenges. A vast array of commercial local pharmacotherapeutic agents had been clinically tested, but the methodologies and clinical results varied within and between each agent used, causing difficulty in drawing conclusions and providing support to the superiority of one agent over another. Considering the benefit-cost ratio with the modest clinical results, the long-term usefulness of these agents remains debatable.

Evaluation of cytotoxic effects of Anbarnesa on fibroblast L929: Can it be used as a mouthwash?

AIMS

In Iranian traditional medicine Anbarnesa (derived from smoke from burning female donkey's stool) has been used to treat ulcers and inflammatory conditions like stomatitis and ear infections (otitis). We assess the properties of Anbarnesa as an alternative mouthwash.

MATERIALS AND METHODS

In this experimental study, Anbarnesa smoke was analyzed using aGC-mass device. The smoke collected was dissolved at different densities in propylene glycol and incubated in Dulbecco's modified Eagle's medium in direct contact with fibroblast cells. Assessment of cytotoxicity was done at 1, 24 and 72 h. Cell viability was measured by methyl thiazolyl tetrazolium test, and ELISA Reader machine was used to read the results. Data were analyzed using one-way ANOVA test.

RESULTS

The findings of this study showed Anbarnesa was nontoxic in 1/64, 1/128 and 1/256 dilutions. In 1/32 dilution, toxicity was seen after 72 h. In dilutions, 1/8 and 1/16 toxicity were seen in the 1(st) h.

CONCLUSION

According to the initial results of Anbarnesa may be used as an alternative mouthwash with fewer side-effects for plaque control and prevention of periodontal disease.

Minocycline HCl Microspheres Reduce Red-Complex Bacteria in Periodontal Disease Therapy

BACKGROUND

The objective of this trial was to measure the antimicrobial effects of a minocycline HCl microsphere (MM) local drug-delivery system when used as an adjunct to scaling and root planing (SRP). DNA probe analysis for 40 bacteria was used to evaluate the oral bacteria of 127 subjects with moderate to advanced chronic periodontitis.

METHODS

Subjects were randomly assigned to either SRP alone (N = 65) or MM + SRP (N = 62). The primary endpoints of this study were changes in numbers and proportions of the red-complex bacteria (RCB) and the sum of Porphyromonas gingivalis, Tannerella forsythia (formally T. forsythensis), and Treponema denticola relative to 40 oral bacteria at each test site from baseline to day 30. Numbers of RCB from the five test sites were averaged to provide a value for each subject.

RESULTS

MM + SRP reduced the proportion of RCB by 6.49% and the numbers by 9.4 x 10(5). The reduction in RCB proportions and numbers by SRP alone (5.03% and 5.1 x 10(5), respectively) was significantly less. In addition, MM + SRP reduced probing depth by 1.38 mm (compared to 1.01 mm by SRP alone), bleeding on probing was reduced by 25.2% (compared to 13.8% by SRP alone), and a clinical attachment level gain of 1.16 mm (compared to 0.80 mm by SRP alone) was achieved.

CONCLUSION

These observations support the hypothesis that RCBs are responsible for periodontal disease and that local antimicrobial therapy using MM + SRP effectively reduces numbers of RCBs and their proportions to a greater extent than SRP alone.

Cost-benefit, cost-effectiveness and cost-utility analyses of periodontitis prevention

OBJECTIVE

The aim of this paper was to determine whether there is evidence that periodontitis prevention is economically justified.

MATERIAL AND METHODS

The characteristics of economic assessments such as cost-benefit, cost-effectiveness and cost-utility analyses were first derived from the literature on health economy. A literature search was conducted using PubMed up to December 2004. Inclusion criteria required that economic analyses be based on scientific principles including a hypothesis, valid comparative groups as well as a cost/benefit, cost/effectiveness and cost/utility assessment.

RESULTS

Only 14 papers were located, which included, in the broadest sense, economic parameters. From these papers, three were systematic reviews, three were randomized controlled studies, four were controlled studies, one was a longitudinal cohort study and three papers were based on statistical modelling. Only one paper reported actual costs for periodontal and dental treatment. Extensive programmes aimed at prevention of periodontal disease in a general population group showed no economic benefit. Adjunctive genetic/and or microbiological testing likewise showed no economic benefit. Economic assessments and real costs are not generally available in the literature. Statistical modelling suggested that non-surgical periodontal procedures are more economical compared with surgical interventions. The use of local delivery devices as an adjunct to Sc/RP showed no economic advantage.

CONCLUSION

It is suggested that economic parameters as well as patient-centred outcomes be included in clinical trials. These data are essential for the appropriate allocation of resources for preventive measures on an individual patient and population base.

Future treatment and diagnostic strategies for periodontal diseases

Many new technologies have been developed or are being developed that could enhance the ability to diagnose, predict, and treat periodontitis. Newer treatment strategies may allow clinicians to achieve limited or more robust regeneration of the periodontium. New or refreshed approaches to disease control are being pursued that will benefit those suffering from chronic periodontal disease. In addition to novel therapeutics, there has been increasing focus on the development of more sensitive and specific diagnostic tests for periodontal diseases. Such tests will allow the clinician to determine whether a patient has active disease and what sort of attachment loss might be expected if the patient is not treated. By developing newer diagnostic tests, it also may be possible to detect and monitor active disease during therapy.

Endodontic-periodontal locally delivered antibiotics

Endodontic pathology is a bacterial disease. It is well established that periapical disease is the result of bacteria, their product, and the host response to them. Periradicular disease will occur after microorganisms and their metabolic products affect the periradicular tissue. Aim of using antibiotics as part of a treatment regimen is to achieve, within the periodontal environment, a concentration of the drug that is sufficient either to kill (bactericidal) or arrest the growth (bacteriostatic) of pathogenic microorganisms. There are two possible approaches to improve the drug action: sustained and controlled drug release to reduce or eliminate side effects by improving the therapeutic index and site-specific drug delivery to minimize systemic effects. These two strategies have been explored by the association of drugs with different vehicles, either naturals or synthetics. A wide variety of specialized local delivery systems (i.e.intrapocket devices) have been designed to maintain the antibiotic in the GCF (gingival crevicular fluid) at a concentration higher than the MIC (minimum inhibitory concentration). Fibres, films, strips and microparticles made of biodegradable or non-biodegradable polymers have been reported as effective methods to administer antibacterial agents for periodontal therapy. Together with these solid devices, semisolid adhesive or non-adhesive formulations have also been proposed.

Mechanism of inhibition of matrix metalloproteinase-2 expression by doxycycline in human aortic smooth muscle cells

Degradation of the extracellular matrix components elastin and collagen has been implicated in vascular diseases, including abdominal aortic aneurysm (AAA) and atherosclerotic plaque rupture. Increased expression of matrix metalloproteinases (MMPs) is involved in these disease processes. Our previous studies have demonstrated that MMP-2 derived from mesenchymal cells is required for aneurysm development in a murine model. Doxycycline is a nonspecific inhibitor of MMPs. In the present study, the mechanisms of the inhibitory effects of doxycycline on MMP-2 expression from cultured human aortic smooth muscle cells (SMCs) and human aortic aneurysm tissue explants were studied. Doxycycline inhibited MMP-2 expression from cultured SMCs in a concentration-dependent manner (5-40 microg/mL; inhibitory concentration of 50%, 6.5 microg/mL). At normal therapeutic serum concentration (5 microg/mL) doxycycline significantly reduced MMP-2 production from SMCs (37%; P <.05), which were stimulated with conditioned media from macrophage or lymphocyte co-culture simulating the inflammatory milieu of AAA tissue. This correlated with a decrease in MMP-2 mRNA half-life, from 49 hours to 28 hours, which suggests that doxycycline inhibits SMC MMP-2 production in part by reducing MMP-2 mRNA stability. When AAA tissue was cultured for 10 days with doxycycline at concentrations of 2.5 to 40 microg/mL, the media exhibited a concentration-dependent decrease in both active and latent forms of MMP-2 and MMP-9. Doxycycline at a concentration of 5 microg/mL reduced active and latent MMP-2 secreted from cultured AAA tissue by 50% and 30%, respectively (P <.05). These study findings demonstrate that doxycycline at standard therapeutic serum concentrations inhibits MMP-2 expression from cultured human aortic SMCs and AAA tissue explants. Inasmuch as MMP activity contributes to extracellular matrix degradation in AAAs and atherosclerotic plaque, doxycycline may have potential value in treating these diseases.